Refining risk stratification in acute pulmonary embolism: A comparative validation of six prognostic scores in a real-life cohort.

ABSTRACT Background Concomitant surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) generally carries a higher operative mortality than isolated SAVR or CABG but also conveys survival benefit. Our aim was to identify factors associated with adverse short and long-term outcomes in this patient group. Research design and methods All consecutive patients undergoing first-time SAVR & CABG in two cardiac surgery centers between 2004 and 2024 were included. Primary outcomes were in-hospital & 1-year mortality and overall survival. Secondary outcomes were post-operative complications and post-operative length of stay (PLOS). Cox multivariable regression was used to identify variables independently associated with overall survival. Results 2617 patients were included. Mean age was 73.5 years (±8.1) and 26.7% (n = 700) were female. In-hospital and 1-year mortality were 3.1% (n = 82) and 7.0% (n = 182), respectively. The incidence of post-operative stroke was 3.6% (n = 94). Median follow-up time was 82 months (49–119) and estimated median overall survival was 106 months (102–110). Despite higher early mortality, receiving a greater number of grafts was independently associated with improved long-term survival. Conclusions Findings from this study suggest that SAVR & CABG remains a safe and effective treatment option for appropriately selected patients with acceptable peri-operative morbidity and reassuring long-term durability.

Pneumothorax in COVID-19: A Negative Prognostic Indicator for In-hospital Mortality.

Acute aortic dissection (AD) and intramural hematoma (IMH) are associated with high mortality, necessitating reliable early risk prediction. The shock index (SI) is a potential prognostic marker in critical care, but its value in AD/IMH remains unclear. This study evaluated the association between admission SI and in-hospital all-cause mortality. This single-center retrospective cohort study included 1250 patients with acute AD/IMH, stratified by an optimal SI cut-off of 0.6 determined by ROC analysis. Kaplan-Meier curves and Cox proportional hazards models were used to assess the relationship. Subgroup analyses were also conducted to confirm the consistency of the main findings. The 30-day cumulative in-hospital all-cause mortality was significantly higher in the SI ≥ 0.6 group than in the SI < 0.6 group (Total: 25.7% vs. 14.4%, p < 0.001; Stanford A: 35.5% vs. 25.2%, p < 0.001; Stanford B: 13.4% vs. 4.8%, p < 0.001). An SI ≥ 0.6 was independently associated with increased in-hospital mortality (adjusted hazard ratio (aHR) 1.67, p = 0.004), consistent across Stanford A (aHR 1.52, p = 0.038) and Stanford B (aHR 2.57, p = 0.014) subgroups. Furthermore, the association was stronger among patients managed without surgery or thoracic endovascular aortic repair (TEVAR) (Total: aHR 2.02, p < 0.001; Stanford A: aHR 1.77, p = 0.009; Stanford B: aHR 3.30, p = 0.004). An admission SI ≥ 0.6 is independently associated with increased in-hospital all-cause mortality in acute AD/IMH, particularly among those managed without surgery/TEVAR. Admission SI may serve as a simple, rapid, and valuable tool for early clinical risk stratification.

To evaluate the impact of diabetes on in-hospital outcomes among patients with metabolic dysfunction-associated steatotic liver disease (MASLD) who were hospitalized for cardiovascular disease (CVD). We conducted a retrospective cross-sectional study using data from the nationwide Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination, from April 2012 to March 2023. A total of 10,614 patients with MASLD hospitalized for CVD were identified, of whom 4550 (42.9%) had diabetes. The primary outcome was in-hospital mortality, and secondary outcomes were major cardiac and non-cardiac complications. The median age was 66 years, and 66.9% were male. Compared with patients without diabetes, those with diabetes had higher rates of ischaemic heart disease (35.5% vs. 30.8%), acute coronary syndrome (18.8% vs. 16.9%) and heart failure (27.3% vs. 25.4%) (all p < 0.05). In-hospital mortality (5.6% vs. 3.3%; p < 0.001) and overall complication rates (23.6% vs. 19.7%; p < 0.001) were significantly greater in the diabetes group, driven mainly by cardiac events (16.8% vs. 10.5%; p < 0.001). Multivariable logistic regression confirmed diabetes as an independent predictor of in-hospital mortality (odds ratio, 1.99; 95% confidence interval, 1.60-2.47; p < 0.001). Diabetes was associated with higher in-hospital mortality and complication rates among patients with MASLD hospitalized for CVD. Stratification of MASLD by metabolic phenotype, particularly in the presence of diabetes, may help improve risk assessment and inform more personalized clinical management in this population.

Electrical Risk Score derived from standard ECG predicts mortality in sepsis patients presenting to the emergency department.

Comparative Outcomes of Transferred vs Nontransferred Cardiogenic Shock Patients Receiving Impella Support.

Cardiogenic shock (CS) is a critical condition of end-organ hypoperfusion with high mortality. Fluctuations in blood glucose (BG) levels may exacerbate cardiovascular instability in critically ill patients. Time In Tight Range (TITR), defined as the percentage of time in the target BG range of 3.9-7.8 mmol/L (70-140 mg/dL), has become an increasingly important index of glycaemic status, but its impact on mortality in CS remains unclear. Interpretable machine learning (ML) models provide transparent, quantitative and visual insights into the prognostic importance of TITR, clarifying its pivotal role in outcome prediction and providing objective evidence to support individualised glucose management. This study aimed to investigate the relationship between TITR and mortality in patients with CS, and to provide strong evidence for early intervention and personalised blood glucose management. We conducted a retrospective multi-cohort study to examine the association between TITR and mortality in patients with CS. The relationship between TITR and in-hospital mortality was analysed using a restricted cubic spline (RCS) model, log-rank test, multivariable Cox and logistic regression analyses. ML models, including XGBoost, LightGBM, CatBoost, Gradient Boosting, Support Vector Machine (SVM), Neural Network and Naive Bayes, were developed to predict mortality and compared with traditional clinical scoring systems. Model interpretability was assessed using SHapley Additive exPlanations (SHAP). Sensitivity and subgroup analyses were used to reveal the robustness of the results. RCS analysis revealed an inverse (L-shaped) association (p < 0.001) between TITR and in-hospital mortality in both the Medical Information Mart for Intensive Care IV (MIMIC-IV) and the eICU Collaborative Research Database (eICU) cohorts. Kaplan-Meier survival analyses revealed the patients with TITR > 57% (High TITR group) had significantly lower in-hospital mortality than those with TITR ≤ 57% (Low TITR group) in both cohorts. The hazard ratios (HRs) (95% confidence interval [CI]) estimated by log-rank test were 1.72 (1.49, 1.99) and 1.49 (1.19, 1.87) in the MIMIC-IV and eICU cohorts, respectively (both p < 0.001). Sensitivity analyses yielded consistent results, confirming the robustness of the findings. In addition, analyses of ICU mortality, 28-day mortality (only available in the MIMIC-IV cohort), also demonstrated a consistent pattern with the primary outcome. Based on area under curve values (AUC), ML models, including CatBoost (AUC = 0.76; 95% CI: 0.73-0.80 in MIMIC-IV; 0.77; 95% CI: 0.72-0.83 in eICU), Gradient Boosting (AUC = 0.75; 95% CI: 0.72-0.79 and 0.74; 95% CI: 0.68-0.80) and XGBoost (AUC = 0.74; 95% CI: 0.70-0.77 and 0.76; 95% CI: 0.71-0.82), outperformed traditional scoring systems. Interpretability analysis via SHAP consistently highlighted TITR as the most influential factor in mortality prediction. These findings underscore the critical role of TITR in outcome prediction and demonstrate both the superiority and interpretability of ML models for risk stratification and decision support. Achieving higher TITR is associated with improved outcomes, highlighting the importance of dynamic glucose control in this population. The findings offer evidence-based guidance for ICU nursing interventions, highlighting TITR as a key modifiable factor for improving outcomes for patients with CS. The strong performance of ML models supports their clinical application for more accurate risk stratification, while identification of TITR as the primary mortality predictor-reinforced by transparent SHAP explanations-provides actionable insights to guide early, targeted interventions.

To evaluate the association between intraoperative indexed oxygen delivery (DO₂i) during cardiopulmonary bypass (CPB) and postoperative outcomes in patients undergoing reoperative cardiac surgery. Retrospective cohort study. A tertiary academic cardiac surgery center. A total of 343 patients who underwent reoperative cardiac procedures between January 2011 and January 2021. Patients were stratified by the median DO₂i threshold predictive of in-hospital mortality, identified using Youden's Index. Median DO₂i was 300.8 ± 52.3 mL/min/m². In-hospital mortality was 14.6%. A median DO₂i <289.4 mL/min/m² predicted mortality (area under the curve = 0.756, sensitivity 78%, specificity 64%). Multivariable analysis showed that each 1 mL/min/m² decrease in DO₂i increased mortality risk by 1.6% (odds ratio [OR] 1.016, 95% confidence interval [CI] 1.007-1.024). DO₂i below the threshold was associated with a fourfold higher mortality risk (OR 4.12, 95% CI 1.18-9.49). After inverse-probability-of-treatment weighting, patients with low DO₂i had higher mortality (21.6% v 6.6%; p < 0.001), acute kidney injury (p = 0.042), cardiac morbidity (51.1% v 38.5%; p < 0.001), and prolonged ventilation (14.3% v 8.3%; p = 0.015). Reduced intraoperative DO₂i was independently associated with increased risk of mortality and major morbidity following reoperative cardiac surgery. Incorporating continuous DO₂i monitoring and optimization into CPB management may improve outcomes in this high-risk population.

Even though tremendous effort has been undertaken within the past 40 years, both sepsis incidence and mortality remain high. The concept of various immune responses in sepsis, ranging from immune paralysis to severe hyperinflammation, has gained more and more attention. As such, the hyperinflammatory phenotype macrophage activation-like syndrome (MALS) became the cornerstone in the latest intervention trials. Our study sought to systematically investigate MALS patients, including their definitions, respective bone marrow markers and monocytic HLA-DR expressions. In this secondary analysis of a retrospective observational study, we included all patients aged ≥18 years and admitted to any adult ICU at Charité - Universitätsmedizin Berlin between January 2006 and August 2018, who had hyperferritinemia (≥500 μg/L) and sepsis, but no diagnosis of hemophagocytic lymphohistiocytosis. For diagnosis of MALS, we used the latest definition of ferritin ≥4420 µg/L. 1629 patients were included, of whom 322 were diagnosed with MALS (19.8%). In-hospital mortality was 62.4% in MALS patients compared to 30.5% in those without MALS. MALS patients had increased macrophage counts and higher rates of activated macrophages in bone marrow biopsies. HLA-DR expression did not differ significantly between the groups. In multivariable logistic regression analysis, MALS showed the highest odds ratio associated with in-hospital mortality. Different definitions of MALS identified largely distinct patient populations. MALS increased in-hospital mortality in sepsis patients. Our results underscore the urgent need for targeted research and therapeutic strategies. While promising insights into immune modulation have emerged, further studies are essential to refine treatment approaches and improve outcomes in this vulnerable patient population.

Acute pyelonephritis in the emergency department: Comparing clinical and prognostic outcomes for community and long-term care.

The test characteristics of ONSD and ODE tests in predicting the prognosis of patients with traumatic brain injury.

IntroductionThe Modified Early Warning Score (MEWS) is a validated tool for the early identification of deteriorating patients; however, its utility in resource-limited surgical settings remains underexplored.MethodsWe conducted a prospective cohort study of 121 adult surgical inpatients residing on general wards at Kamuzu Central Hospital in Lilongwe, Malawi. Critical illness was defined using the Modified Early Warning Score (MEWS), with a score ≥5 indicating critical illness. Data were collected on a single day through standardized bedside assessments and chart reviews, capturing demographic and clinical information. Patients were followed up at day 7 and day 30 to determine mortality outcomes.ResultsOf the 121 patients, 15 (12.4%) met critical illness criteria. The median age of critically ill patients was 50 years (IQR = 23-64). Most patients meeting critical illness criteria (86.7%, n = 13) were managed on general wards. At days 7 and 30, in-hospital mortality rates were 5.0% (n = 6) and 9.9% (n = 12), respectively. Mortality rates were significantly higher among critically ill patients compared to non-critically ill patients at days 7 and 30: 20.0% vs 2.8% (P = 0.004) and 33.3% vs 6.6% (P = 0.001), respectively. In multivariable logistic regression analysis, the MEWS was the only significant predictor of 30-day mortality (OR = 1.62, 95% CI: 1.11-2.38, P = 0.013), with mortality probability approaching 40% at an MEWS of 10.ConclusionThe MEWS effectively identified high-risk surgical inpatients in our setting. Integrating the MEWS into surgical practice may improve outcomes for critically ill surgical patients.

Impact of mass resident physician resignation on inpatient mortality and admissions in Korea.

Long-Term Outcomes Following Traumatic Injury in Older Adults in Pakistan: A Prospective Cohort Study.

Incorporation of sputum real-time RT-PCR into routine diagnostics increases case detection of respiratory syncytial virus lower respiratory tract infections in older adults.

An evaluation of emergency exploratory laparotomy timing & outcomes in adult patients with severe penetrating abdominal trauma in hemorrhagic shock.

Outcomes of critically ill patients with obesity hypoventilation syndrome presenting with acute hypercapnic respiratory failure.

Impact of vasopressin initiation at norepinephrine dose thresholds in septic shock patients with high SOFA scores: A retrospective observational cohort study.

Anesthesia choice affects hip fracture surgery outcomes. However, limited evidence exists regarding the impact of neuraxial anesthesia (NA) versus general anesthesia (GA) on postoperative outcomes, specifically in hip arthroplasty for fracture. The purpose of this study was to compare 30-day readmission, in-hospital complications, hospitalization charges, and length of stay between the elderly who received NA and GA during this procedure. The Hospital Quality Monitoring System was analyzed for patients undergoing hip arthroplasty for geriatric hip fracture (≥60 years of age) between 2013 and 2019. After adjusting for potential confounders with propensity score matching, logistic regression and linear regression analyses were conducted to compare NA with GA in terms of 30-day readmission rates and causes, in-hospital complications (including in-hospital mortality, pulmonary embolism, deep vein thrombosis, wound infection, and blood transfusion), hospitalization charges, and length of stay. Of the 90,745 patients undergoing hip arthroplasty for geriatric hip fracture during the study period (40,551 [44.7%] for NA, 50,194 [55.3%] for GA), a total of 62,022 patients (31,011 propensity score-matched pairs) were included after study exclusions and propensity score matching. NA was significantly associated with a lower incidence of 30-day readmission (4.60% vs 4.97%, odds ratio [OR] = 0.92, 95% confidence interval [CI], 0.86-0.99, P =.032) and fewer genitourinary system complaints (0.18% vs 0.26%, OR = 0.70, 95% CI, 0.50-0.97, P =.035) for readmission compared with GA. The incidence of in-hospital mortality (0.41% vs 0.64%, OR = 0.64, 95% CI, 0.52-0.81, P <.001), deep vein thrombosis (1.84% vs 2.57%, OR = 0.71, 95% CI, 0.64-0.79, P <.001), and pulmonary embolism (0.22% vs 0.38%, OR = 0.58, 95% CI, 0.43-0.79, P <.001) was also lower for NA compared with GA. Moreover, patients with NA had decreased charges (49,851.8 Chinese Yuan [CNY] vs 54,754.8 CNY, P <.001) relative to GA. The length of stay did not differ significantly between NA and GA (13.7 days vs 13.8 days, P =.217). In geriatric patients undergoing hip arthroplasty for hip fracture, NA is associated with lower rates of 30-day readmission, fewer readmission caused by genitourinary system complaints, reduced complications, and decreased hospitalization charges compared to GA.